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A study to determine the type and frequency of interruptions sustained by postcardiotomy patients in… Nicholson, Billie Patricia 1974

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A STUDY TD DETERMINE THE TYPE AND FREQUENCY OF INTERRUPTIONS SUSTAINED BY POSTCARDIOTOMY PATIENTS IN AN INTENSIVE CARE UNIT  by BILLIE  PATRICIA NICHOLSON  B.N.-, MCGILL UNIVERSITY, 1965  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING  In the School of Nursing  We a c c e p t  this  to the r e o u i r e d  t h e s i s as  conforming  standard.  THE UNIVERSITY OF B R I T I S H COLUMBIA April,  1974  In p r e s e n t i n g an  advanced  the I  Library  further  for  degree shall  agree  thesis  in partial  fulfilment  of  at  University  of  Columbia,  the  make  that  this  written  it  may b e  representatives. thesis  for  freely  It  financial  permission.  Department  of  The U n i v e r s i t y o f B r i t i s h V a n c o u v e r 8, Canada  by the  understood  gain  Columbia  for  extensive  granted  is  British  available  permission for  s c h o l a r l y purposes  by h i s of  this  shall  requirements I  agree  reference  and  copying of  this  be  for that  study. thesis  H e a d o f my D e p a r t m e n t  that  not  the  or  copying or p u b l i c a t i o n a l l o w e d w i t h o u t my  ABSTRACT The environment of the intensive care unit i s cited as one etiological  factor of postoperative psychosis i n patients follouing  open-heart surgery.  This descriptive study uas undertaken to  document the type and frequency of interruptions sustained by postcardiotomy patients i n one intensive care u n i t . The study uas designed to ansuer three questions: 1.  Hou frequent are the interruptions sustained by these  patients? 2.  Hou long are the blocks of uninterrupted time?  3.  What are the types of interruptions?  To c o l l e c t the data a checklist of interrupting a c t i v i t i e s uas u t i l i z e d .  The sample included 108 hours of observation that  covered the f i r s t f i f t y - s i x postoperative hours.  These hours uere  divided into early, mid, and late postoperative periods uith six hours of observation i n each period.  To f a c i l i t a t e  observation, the observation periods uere divided into blocks.  thirty-  continuous four-hour  A random sampling of the four-hour time blocks i n each  postoperative period over the days of the ueek uas carried out. A descriptive analysis of the data collected centered around the three questions.  Also, t D f a c i l i t a t e analysis of data the types  of interruptions uere organized into four main categories: nursing a c t i v i t i e s ,  (2) patient i n i t i a t e d a c t i v i t i e s , ii  (1)  (3) a c t i v i t i e s  iii • f cithers,  and (k)  environment.  B a s i c to the d i s c u s s i o n of the data uiere the f i n d i n g s r e p o r t e d i n the l i t e r a t u r e : f i v e to n i n e t y  (1)  fallowing  adults require  minutes to complete one s l e e p c y c l e ,  (2)  eightythere i s a  c l o s e resemblance betueen the p s y c h o s i s of s l e e p d e p r i v a t i o n and postcardiotomy p s y c h o s i s , iotomy i n t e n s i v e for rest  and (3)  the environment of the p o s t c a r d -  care u n i t i s not conducive to g i v i n g  p a t i e n t s time  and s l e e p . U i t h i n the l i m i t s of the s m a l l sample s i z e  the study i n d i c a t e d t h a t p a t i e n t s uere f r e q u e n t l y Second, the i n t e r r u p t e d to o b t a i n r e s t  and s l e e p .  Finally,  nursing a c t i v i t i e s  care  patients  uere r e s p o n s -  These f i n d i n g s  the f i n d i n g s o f other s t u d i e s undertaken i n the  supported  postcardiotomy  unit.  In a d d i t i o n ,  i m p l i c a t i o n s and recommendations f a r  r e g a r d i n g management of these p a t i e n t s were d i s c u s s e d . recommendations f o r  further  investigation  of  interrupted.  time blocks are not long enough f o r  i b l e f o r 50 percent of the i n t e r r u p t i o n s .  intensive  the f i n d i n g s  nurses  Finally,  uere s u g g e s t e d .  TABLE DF CONTENTS LIST OF TABLES  6  ACKNOWLEDGEMENTS  B  Chapter I. INTRODUCTION TO THE STUDY  1  Introduction Statement o f t h e Problem S i g n i f i c a n c e o f t h e Problem Assumptions o f t h e Study D e f i n i t i o n o f Terms L i m i t a t i o n s o f t h e Study II.  1 3 3 k 5 5  REVIEW OF THE LITERATURE  7  Introduction The 24-Hour S l e e p Wakefulness C y c l e Stages and P a t t e r n s o f S l e e p . . . . . Sleep Deprivation Postcardiotomy Psychosis Environment o f t h e P o s t c a r d i o t o m y I n t e n s i v e Care U n i t E x i s t i n g N u r s i n g Research Summary III.  18 20 2D  METHODOLOGY  22  Introduction Adaptation of the Tool Checklist of Interrupting A c t i v i t i e s The S e t t i n g P a t i e n t Care A c t i v i t i e s The P i l o t Study The Sample C o l l e c t i o n o f t h e Data Summary IV.  7 8 10 Ik 17  ANALYSIS OF THE DATA Presentation of Findings Frequency o f I n t e r r u p t i o n s Length o f U n i n t e r r u p t e d P e r i o d s Types o f I n t e r r u p t i o n s Discussion of Findings Summary iv  •  22 22 22 2k 25 26 27 28 29 30 30 30 31 34 kO k2  V  Chapter  V.  SUMMARY, IMPLICATIONS AND RECOMMENDATIONS FOR NURSING CARE, RECOMMENDATIONS FDR FURTHER INVESTIGATION Summary.... Implications and Recommendations for Nursing Care Recommendations for Further Investigation  BIBLIOGRAPHY  43 43 45 46 47  APPENDIX A. B. C. D. E. F. G.  Checklist of Interrupting A c t i v i t i e s Categories of Types of A c t i v i t i e s Random Sample of Time for Observation Periods... Tables Related to Uninterrupted Time Blocks Tables Related to the Types of Interruptions.... Number of Patients Observed by Sex According to Type of Surgery Tables Related to Interrupted and Uninterrupted Time  52 54 56 58 62 66 68  LIST OF TABLES  1.  Average Time i n Minutes Betueen Interruptions in the Four-Hour Time Blacks i n Each Postoperative Period  31  Number and Duration of Uninterrupted Time Blacks i n the Three Postoperative Periods  32  Average Number and Duration of the Uninterrupted Time Blocks i n the Four-Hour Blacks i n the Three Postoperative.. Periods  33  k.  Number and Percentage of Interruptions i n Each Category u i t h i n the Three Postoperative Periods...  3k  5.  Number of Interruptions i n the Types of A c t i v i t i e s in the Three Postoperative Periods  35  Percentage of Interruptions by Types of Nursing A c t i v i t i e s i n the Three Postoperative Periods  37  Percentage of Interruptions by A c t i v i t i e s of Others in the Three Postoperative Periods  37  Percentage of Interruptions by Environmental A c t i v i t i e s i n the Three Postoperative Periods.....  38  Average Number of Interruptions i n the Categories of A c t i v i t i e s i n the Faur-Hour Blacks i n the Three Postoperative Periods  39  Number and Duration of Uninterrupted Time Blacks in Each Four-Hour Black i n the Early Postoperative Period. ;  59  Number and Duration of Uninterrupted Time Blocks in Each Four-Hour Block i n the Mid Postoperative Period  60  Number and Duration of Uninterrupted Time Blocks in Each Four-Hour Block i n the Late Postoperative Period  61  2. 3.  6. 7. 8. 9.  10.  11.  12.  vi  uii  13.  14.  15.  16. 17.  18.  19.  Number of Interruptions i n the Types of A c t i v i t y Uithin the Four-Hour Time Blocks i n the Early Postoperative Period ....  63  Number of Interruptions i n the Types of A c t i v i t y u i t h i n the Four-Hour Time Blocks i n the Mid Postoperative Period  64  Number of Interruptions i n the Types of A c t i v i t y u i t h i n the Four-Hour Time Blacks i n the Late Postoperative Period  65  Number of Male and Female Patients Observed According to Type of Surgery  67  Number of Minutes of Interrupted and Uninterrupted Time i n Each Four-Hour Block i n the Early Postoperative. Period  69  Number of Minutes of Interrupted and Uninterrupted Time i n Each Four-Hour Block i n the Mid Postoperative Period  70  Number of Minutes of Interrupted and Uninterrupted Time i n Each Four-Hour Block i n the Late Postoperative Period  71  i  ACKNOWLEDGEMENTS I uish to express my appreciation to the many people uho made this study passible: cardiotomy  to the nursing s t a f f i n the post-  intensive care unit for their interest and cooperation;  to Ms. Helen E l f e r t for her help uith the analysis of data; to the members of my committee, Ms. Mary Cruise and Ms. Sue Rothuell, my committee chairman, for their advice and guidance; and to my classmates for their interest and support throughout of this study.  viii  the progression  CHAPTER I INTRODUCTION TO THE STUDY Introduction Along uith other advances made i n medical science over the past twenty years great strides have been made i n open-heart surgery.  Although many patients have benefited from the d i f f e r e n t  cardiotomy procedures one untouiard response, postoperative  psychosis,  has been noted i n many of these patients during their stay i n the intensive care u n i t . Postcardiotomy psychosis has been reported to appear i n approximately heart surgery.  38 percent to 57 percent of adults uho have openThis syndrome i s manifested after a three to f i v e  day l u c i d postoperative period and i s characterized by: perceptual distortions, v i s u a l and auditory hallucinations, disorientation and paranoid ideation.^" A revieu of the research reveals l i t t l e agreement about the etiology of this postoperative reaction.  Although  many factors have been i d e n t i f i e d as the cause, i t appears to r e sult from an interaction among several factors, some p h y s i o l o g i c a l in o r i g i n and others related to psychological s t r e s s .  "'"Donald S. Kornfeld, "Psychiatric Complications of Cardiac Surgery," International Psychiatric C l i n i c s 4 (February 1967): 115.  2 Linda H. Aiken and Theodore F. Henrichs, "Systematic Relaxation As A Nursing Intervention Uith Open Heart Surgery Patients," Nursing Research 20 (May-June 1971): 213. 1  i  Houever, one e t i o l o g i c a l factor that i s of p a r t i c u l a r concern to nurses and one that i s p a r t i a l l y c o n t r o l l a b l e , i s the environment of the intensive care unit.  Kornfeld's study paid  particular attention to the environment of these areas to see i f i t uas a contributing factor i n postoperative psychotic reactions. He concluded that: A major factor appeared to be the environment of the openheart recovery room, uhere intensive nursing and medical care produced an atmosphere of sleep and sensory deprivation. ^ Lazarus also carried out studies on the environment of the postcardiotomy intensive care u n i t . Patients the lack strained they are  He stated:  frequently complain of the frightening atmosphere, of sleep, the feeling of being physically r e and the unusual and disturbing sounds to uhich exposed.^  These tuo studies recommended the modification of nursing procedures to allou for a maximum number of uninterrupted periods.  sleep  Also Kornfeld suggested that the usual day-auake, night-  sleep cycle for each patient should be maintained uhenever possible. Cardiotomy patients and nurses uho uork i n postcardiotomy intensive care units agree that interruptions to patients' sleep and rest are too frequent.  In reviewing  the l i t e r a t u r e there appears to  be l i t t l e research that looked at kinds of interruptions sustained  "^Donald S. Kornfeld, S. Zimberg, and J . R. Malm, "Psychia t r i c Complications of Open-Heart Surgery," The Neu England Journal of Medicine 273 (August 1965): 292. . H. R. Lazarus and J . H. Hagens, "Prevention of Psychosis Follouing Open-Heart Surgery," American Journal of Psychiatry 124 (March 1968): 1190. 5 Kornfeld, "Psychiatric Complications,"  p. 291.  3 by these p a t i e n t s . Nurses a r e r e s p o n s i b l e f o r t h e o r g a n i z a t i o n o f n u r s i n g c a r e . In o r d e r t o modify the o r g a n i z a t i o n o f n u r s i n g c a r e , nurses must be auare o f t h e type and frequency o f i n t e r r u p t i o n s e x p e r i e n c e d by p a t i e n t s i n these a r e a s . Statement The purpose  p f t h e Problem  o f t h i s e x p l o r a t o r y study uas t o document t h e  type and frequency o f i n t e r r u p t i o n s s u s t a i n e d by p o s t c a r d i o t o m y /  p a t i e n t s i n an i n t e n s i v e care u n i t . T h i s study uas designed t o ansuer the f o l l o u i n g q u e s t i o n s : 1.  Hou f r e q u e n t are the i n t e r r u p t i o n s e x p e r i e n c e d by these  patients? 2.  Hou l o n g are t h e b l a c k s o f u n i n t e r r u p t e d time?  3.  What a r e t h e t y p e s o f i n t e r r u p t i o n s ? S i g n i f i c a n c e o f t h e Problem  S l e e p i s one o f t h e f a s c i n a t i n g m y s t e r i e s o f l i f e . needs s l e e p .  Everyone  The f u n c t i o n o f s l e e p s t i l l remains an enigma b u t i t  i s r e c o g n i z e d t h a t s l e e p i s a b a s i c p h y s i o l o g i c a l need.  Sleep de-  p r i v a t i o n s t u d i e s have shoun t h e d e t r i m e n t a l e f f e c t o f l o s s o f s l e e p over l o n g p e r i o d s o f t i m e . H o u e v e r , ' p a t i e n t s i n p o s t c a r d i o t o m y i n t e n s i v e care u n i t s f r e q u e n t l y complain o f l a c k of s l e e p . ^  P a t i e n t s have d e s c r i b e d  ^JoAnna DeMeyer, "The Environment o f t h e I n t e n s i v e Care U n i t , " N u r s i n g Forum 6 (October 1967): 262-72. 7 L. H.Nahum, "Madness i n t h e Recovery Room From Open-Heart Surgery o r They Kept Waking Me Up," C o n n e c t i c u t M e d i c i n e 29 (November 1965): 771-72.  [  their stay i n these areas as a disturbing experience.  They have  especially noted the unusual sounds, the frightening atmosphere, 8 9 and the feeling of being physically restrained. ' The complaints of lack of sleep and the experiences described by patients uho have been i n these areas should concern nurses.  Nurses are responsible for helping the patient.meet his  basic physiological need for sleep.  Judgements about hou best to  modify nursing care to meet this need are the r e s p o n s i b i l i t y of nurses uho uork in the postcardiotomy  intensive care u n i t s . ^  Are patients continually interrupted?  Hou much time i s  actually available to patients far rest and sleep?  These are  questions nurses should be able to ansuer in order to ensure patients are meeting their need for sleep. Assumptions of the Study The study uas based on the follouing 1.  assumptions:  Sleep i s a basic physiological need.  Therefore i f  patients in the intensive care unit are constantly being interrupted they u i l l not have enough time available to meet their physiological need for sleep.  Q  Lazarus, "Prevention of Psychosis," p.  1190.  g hornfeld, "Psychiatric Complications," p. 237. "^Elizabeth F. Pitorak, "Open-Ended Care for the Open-Heart Patient," American Journal of Nursing 69 (September 1969): 1896-99.  5 This assumption i s based an Kleitman's statement that adults require eighty-five to ninety minutes to complete one and a representative  sleep cycle  night's sleep of about eight hours i s l i k e l y  to be made up of five such cycles.''"''' 2.  There i s a close resemblance betueen the psychosis  sleep deprivation and the description of postcardiotomy This assumption i s based on Kornfeld's  of  psychosis.  finding that,  The (postcardiotomy) psychosis...closely resembles the psychosis in sensory and sleep deprivation experiments. The progression from i l l u s i o n s to hallucinations to paranoid reactions i s a t y p i c a l sequence.12 D e f i n i t i o n of Terms Interruption:  used to r e f e r to any stimulus uhich  precip-  itated patient a c t i v i t y or uhich increased the patient's auareness of his environment. Intensive Care Unit:  used to refer to an area designed es-  pecially for the care of the postcardiotomy patient. Limitations of the Study There uere recognized 1.  l i m i t a t i o n s to the study:  The highly s p e c i a l i z e d setting of the study l i m i t s the  application of the r e s u l t s to a l l types of patient care areas. 2.  Limitations imposed by uncontrolled variables  included:  "'""'"Nathaniel Kleitman, Sleep and Wakefulness (Chicago: University of Chicago Press, 1963), pp. 112-13. Donald S. Kornfeld, "Psychiatric Complications of Cardiac Surgery," International Psychiatric C l i n i c s 4 (February 1967): 124.  6 a)  the difference in medical orders regarding  post-  cardiotomy care. b)  the differences in performance of the i n d i v i d u a l nurses uho uere providing patient  c)  care.  the effect of the presence of the investigator upon the patient and the intensive care personnel.  CHAPTER I I REVIEW DF THE  LITERATURE  Introduction In r e v i e w i n g  the l i t e r a t u r e i t uas noted t h a t the  l o g i c a l f a c t o r s of p o s t o p e r a t i v e main c a t e g o r i e s :  (1)  psychosis  the p r e o p e r a t i v e  etio-  uere grouped under  p s y c h o l o g i c a l s t a t e of  i n d i v i d u a l , (2) the uniqueness of the i n t e n s i v e care u n i t ment, and  (3) the p h y s i o l o g i c a l d i s t u r b a n c e s  s u r g i c a l procedure  environ-  r e s u l t i n g from the  d e c i d e d to f o c u s on  second e t i o l o g i c a l f a c t o r , the environment of the i n t e n s i v e The  the  itself.*  For the purpose o f t h i s study i t uas  unit.  three  r e a s o n f o r t h i s f o c u s i s the environment can be  c o n t r o l l e d by n u r s i n g p e r s o n n e l .  The  the  care partially  r e s u l t s of s e v e r a l s t u d i e s  c a r r i e d out i n p o s t c a r d i o t o m y i n t e n s i v e care u n i t s c o n c l u d e d t h a t t h e r e uas  a s i m i l a r i t y betueen the symptoms of p o s t c a r d i o t o m y psy-  c h o s i s and s l e e p d e p r i v a t i o n .  They a l s o recommended t h a t  procedures s h o u l d be m o d i f i e d  to p r o v i d e . a d e q u a t e s l e e p and  maintain  the day-auake, n i g h t - a s l e e p  nursing to  2 3 relationship. '  ^ H e r b e r t R. L a z a r u s and Jerome H. Hagens, P r e v e n t i o n of P s y c h o s i s F o l l o u i n g Open-Heart S u r g e r y , " American J o u r n a l of P s y c h i a t r y 124 (March 1968): 76. 2  I b i d . , p.  80.  "^Donald S. K o r n f e l d , Shelden Zimberg and James R. Malm, " P s y c h i a t r i c C o m p l i c a t i o n s of Open-Heart S u r g e r y , " The Neu England J o u r n a l of M e d i c i n e 273 (August 1965): 291. 7  a For t h i s focused o n :  (1)  reason the l i t e r a t u r e  unit,  (5)  and (6)  this  the 24-hour s l e e p - w a k e f u l n e s s c y c l e ,  and p a t t e r n s of s l e e p , psychosis,  reviewed f o r  (3)  sleep deprivation,  (4)  study  (2)  stages  postcardiotomy  the environment of the postcardiotomy i n t e n s i v e  care  r e l a t e d nursing r e s e a r c h .  The 24-Hour Sleep-Wakefulness Cycle  It  was noted p r e v i o u s l y  that s t u d i e s by Lazarus and K o r n f e l d  recommended that n u r s i n g procedures be m o d i f i e d to m a i n t a i n the u s u a l "day-awake" " n i g h t - a s l e e p " c y c l e s .  What are these c y c l e s and  how do they a f f e c t man? Man i s c o n s c i o u s o f the many c y c l e s w i t h i n nature affect his l i f e , the moon.  such as the seasons of the year or the phases of  However,  the d a y - n i g h t  that  cycle.  the one that e x e r t s This  theory  the g r e a t e s t  influence  i s supported i n the  is  following  statement by M i l l s : Most men are s u b j e c t e d throughout t h e i r l i v e s to an a l t e r a t i o n of l i g h t and darkness with an almost constant c y c l e l e n g t h of 24 h o u r s . T h i s determines a p a t t e r n of behavior with a l t e r n a t i n g p e r i o d s of r e s t , a c t i v i t y , meals, e t c 4 T h i s 24-hour c y c l e has been l a b e l l e d " c i r c a d i a n " from the L a t i n word meaning "about a d a y . "  S c i e n t i s t s used t h i s  the rhythms w i t h i n the c y c l e are not e x a c t l y  term because  24 hours but have a  J. M i l l s , "Human C i r c a d i a n Rhythms," P s y s i o l o q i c a l Reviews 46 (January 1966): 129.  9  p e r i o d of a p p r o x i m a t e l y 2k h o u r s . The c i r c a d i a n rhythms appear to r e s u l t  from tuo  (1) an i n t e r n a l b i o l o g i c a l c l o c k , p o s s i b l y u i t h i n the and (2) s y n c h r o n i z e r s  i n the e x t e r n a l environment,  factors:  hypothalmus,  of uhich  light  and s o c i a l f a c t o r s are the most i m p o r t a n t . ^ The importance o f these c i r c a d i a n rhythms i s becoming i n c r e a s i n g l y r e c o g n i z e d because they appear to i n f l u e n c e many p h y s i o l o g i c a l f u n c t i o n s of the human body.  Some of the  physiological  parameters t h a t have shoun these rhythms and f u n c t i o n u i t h maximum and minimum p e r i o d s o f a c t i v i t y ature, heart r a t e ,  are:  m e t a b o l i c r a t e , body temper7  l e v e l o f hormones, and r e n a l b l o o d f l o u .  most f a m i l i a r one i s body temperature because i t measure.  It  hours.  The  i s the e a s i e s t  r i s e s and f a l l s u i t h c l o c k - l i k e r e g u l a r i t y  to  each 2k  The l o u e s t body temperature o c c u r s d u r i n g s l e e p and the  g h i g h e s t d u r i n g the time a person i s more a c t i v e or  alerts  Man and h i s environment are i n c o n s t a n t i n t e r a c t i o n  uith  each o t h e r . Menaker s t a t e s : . Organisms are not p a s s i v e r e s p o n d e r s . They have i n t e r n a l a c c u r a t e t i m e - m e a s u r i n g systems or ' c l o c k s ' . The e n v i r o n 5 N a t h a n i e l H l e i t m a n , S l e e p and Wakefulness ( C h i c a g o : U n i v e r s i t y of Chicago P r e s s : 1 9 6 3 ) , p. 1 3 2 . P  ^R. T. Li. L. Conroy, " J e t T r a v e l and C i r c a d i a n Rhythms," N u r s i n g Times 68 (March 1 9 7 2 ) : 3 7 1 . 7 M i l l s , "Human C i r c a d i a n Rhythms," p p .  g  128-71.  U. S . , Department of H e a l t h , E d u c a t i o n and W e l f a r e , C u r r e n t Research on S l e e p and Dreams (Washington, D . C . : P u b l i c Health S e r v i c e P u b l i c a t i o n No. 1389, 1965), p. 5 .  i  10 ment acts on the organism to keep the clock set to correct time.9 Hou f l e x i b l e are these 24-hour cycles? that although  Studies have proven  the daily pattern of rhythms varies from one  indiv-  idual to another, individuals, very rarely, can function on a cycle that i s not approximately  24 hours long."*"^  Kleitman's famous ex-  periment shoued that subjects in time can adjust to a 21-hour or 28-hour day.  Houever, i f the timetable varies from the 24-hour  day by three hours either uay most subjects cannot adjust.  Also the  younger subjects can adapt easier than the older ones."'""'" This experiment and others support the hypothesis about the b i o l o g i c a l clock that controls the rhythms of the body, that it  "runs on a 24-hour schedule, uhich can be altered only s l i g h t l y 12  and only i f given time to adjust." Stages and Patterns of Sleep In recent years, research into the phenomenon of sleep has revealed that i t i s not a single uniform state but a complex and dynamic one.  The electroencephlogram  has helped i d e n t i f y the d i f f e r -  ences in brain a c t i v i t y betueen the sleeping and uaking state, and g Michael Menaker, "Biological Clocks," Bioscience 19 (August 1969): 681. •^U. S. Department of Health, Education and Uelfare, Current Research on Sleep and Dreams, p. 5. ^Kleitman,  Sleep and [Wakefulness, pp. 172-84.  12 Nicole Beland-Marchak, "Circadian Rhythms," Canadian Nurse 64 (December 1968): 41.  11 those a c t i v i t i e s that characterize the stages of sleep. The stages of sleep as outlined by Dement and Kleitman are the most widely accepted.*^  From E.E.G. readings they i d e n t i f i e d  the five stages of sleep and stated that an i n d i v i d u a l progresses from Stage 1 to Stage 4 and moves progressively back up the stages to Stage 1.  Rapid eye movement (REM) sleep i s the stage when the  person i s ascending from Stage 2 to Stage 1 uhich i s d i f f e r e n tiated from descending Stage 1.  This term i s used because during  this stage jerky, rapid eye movements can be seen beneath the closed eyelids of the sleeper." "^ 1  In the past there has been confusion uith the terminology used to describe the stages of sleep.  Houever, today the acceptable  standard terminology used i s rapid eye movement (REM)  and non rapid  eye movement (NREM) and the l a t t e r i s further subdivided into four numbered stages. In healthy adults a representative night's sleep of about eight hours i s made up of approximately five of uhat Kleitman termed basic rest a c t i v i t y cycles, referred to as BRAC, that are about  W. C. Dement and Kleitman, "Cyclic Variations in E.E.G. During Sleep and Their Relation to Eye Movements, Body M o t i l i t y and Dreaming," Electroencephloqraphy and C l i n i c a l Neurophysiology 9 (November 1957): 673-90. 14 E. Aserinsky and N. Kleitman, "Tuo Types of Occular M o t i l i t y Occurring in Sleep," Journal of Applied Physiology 8 (July 1955): 1-10. 15 (Illinois:  Frank R. Freeman, Sleep Research; A C r i t i c a l Revieu Charles C. Thomas, 1972), p. 4.  12 eighty-five to ninety minutes i n length."^  I t has also been hypoth17  esized that these BRAC operate during the making hours as u e l l . A t y p i c a l night's sleep i n young adults has been described in a number of studies.  I t has been noted that i n i t i a l l y a person  going to sleep descends from Stage 1 to Stage 2, to Stage 3 and to Stage 4 i n that order.  In Stage 1, the person may experience a  f l o a t i n g sensation or d r i f t i n g .  His body muscles are r e l a x i n g .  He  can be e a s i l y auakened by a noise or spoken uord and i f auakened he may assert he has not been sleeping. minutes.  This stage lasts only a feu  As the person descends into Stage 2 he i s more relaxed  but he s t i l l auakens e a s i l y as i n Stage 1.  Houever, i f auakened at 18  this paint a person might f e e l he had been "indulging i n reverie." In  Stage 3 sleep a person's muscles become very relaxed,  v i t a l . s i g n s decrease and he i s mare d i f f i c u l t to auaken.  A person  is i n deep sleep i n Stage k. He i s very relaxed and rarely moves-, i f he i s auakened he u i l l respond very s l o u l y .  After about seventy  minutes of predominately Stages 3 and k IMREM sleep, the f i r s t REM sleep occurs.  In this stage, rapid eye movements.are seen, v i t a l  signs become exceedingly variable and v i v i d dreaming takes place. After about ten to f i f t e e n minutes of REM sleep a person u i l l "^Kleitman, Sleep and Uakefulness, p. 113.  descend  17 Nathaniel Kleitman, "Basic Rest-Activity Cycle i n Relation to Sleep and Uakefulness," Sleep; Physiology and Pathology ed. Anthony Kales (Philadelphia and Toronto: J . B. Lippincott Co., 1969), p. 37. U. S. Department of Health, Education and Uelfare, Current Research on Sleep and Dreams, p. 11.  13  again to Stage k.  19  As the night progresses the r a t i o of REM sleep increases. Studies show stage U sleep occurs predominately :  during the f i r s t  t h i r d of the night, and REM sleep predominates the f i n a l t h i r d of the night.  About twenty to twenty-five percent of the t o t a l  sleep of young adults i s spent i n REM sleep, 5 percent i n stage 1 (IMREM), 5 0 percent i n stage 2 , and 2 D percent i n stages 3 and 4 combined. '"' 2  The pattern of sleep from night to night i n a single individual remains r e l a t i v e l y constant, although patterns vary from individual to i n d i v i d u a l .  However, with increasing age a very s l i g h t  decrease i n REM percentage and a somewhat larger decline i n IMREM, .  2  1  stage, may occur. In recent years the great interest i n sleep research shown by s c i e n t i s t s has led to the forming of many hypotheses the function of the various stages of sleep.  to explain  There have been several  theories advanced especially i n regard to REM and IMREM, stage k, sleep.  I t was hypothesized that the former was needed to deal with  s t r e s s f u l experiences and the l a t t e r was required to provide a chance for rest and relaxation.  However, more recent theories state that  each stage i s v i t a l and necessary. Our increasing knowledge about sleep seems to indicate that each stage serves different organismic functions and 19  Ibid., pp.  11-13.  2D  R. J . Berger, "The Sleep and Dream Cycle," Physiology and Pathology, p. 2 1 . 21  Freemon, Sleep Research, p. 1 1 .  Sleep:  i s therefore characterized by different clusters of physiological activities.22 The physiological changes that occur during sleep have been investigated by many researchers.  IMREM, Stage k, sleep has been  described as the 'quieter phases' of sleep.  It i s characterized  by slau, steady heart and respiratory rates, louer blood pressure, absence of rapid eye movement, a decrease in muscular tonus and decrease in body temperature.  In REM  sleep there i s a transitory  increase in s y s t o l i c blood pressure, heart rate, respiratory rate and in tuitching movements of the muscles of face and limbs.  23 2k '  Sleep Deprivation Despite the extended knouledge of the physiology, neurophysiology, biochemistry  and psychology of sleep the restorative  function of sleep s t i l l remains an enigma.  One  approach to studying  the function of sleep i s to examine uhat happens to an i n d i v i d u a l uho i s deprived of sleep. There have been many studies carried out in the laboratory that look at uhat happens to individuals uho are deprived of sleep. These experiments have studied three main types of sleep deprivation:  (1) t o t a l , (2) p a r t i a l , and (3) d i f f e r e n t i a l .  Studies of  t o t a l and p a r t i a l deprivation usually focus on the length of time 22 R. J . Berger, "Physiological Characteristics of Sleep," Sleep; Physiology and Pathology, p. 72. 2 3  I b i d . , pp. 68-79.  2k  Fredrick H. Loury, "Recent Sleep and Dream Research: C l i n i c a l Implications," Canadian Medical Association Journal 102 (May 1970): 1069-77.  15 given to sleep.  D i f f e r e n t i a l sleep deprivation involves depriv-  ation of any one of the stages of sleep. The results of studies on t o t a l sleep deprivation uere dependent upon the length of time subjects went without sleep. subjects who  In  were awake sixty hours, neurological examinations  showed weakness of f l e x i o n of the neck, hand tremor, awkwardness, nystagmus, ptosis, dysarthria, poverty of f a c i a l movements, peculiar preoccupation  with details especially those related to personal be25  longings, short attention span and an apathetic appearance. After 100 to 120 hours without  sleep subjects experienced  distortions, such as halos around objects, which may  visual  progress to  frank visual h a l l u c i n a t i o n s . Also in some individuals paranoid ideation may may  become prominent.  However, i t was  found that subjects  ILry to conceal these psychotic symptoms, therefore they  e a s i l y be missed by the researcher. time included:  may  Neurological findings at t h i s  s l u r r i n g of speech, i n a b i l i t y to concentrate, i n -  creased s e n s i t i v i t y to pain, episodes of disorientation to time, 26 and immediate memory loss such as forgetting the task at hand. However, further studies have shown that these neurological changes associated with sleep loss are transitory and after one or two nights of recovery sleep there i s a dramatic reversal of the 27 pattern of behavior. Recovery from these acute symptoms i s 25 J . F. Sassin, "Neurological Findings Following Short Term Sleep Deprivation," Archives of Neurology 22 (January 1970): 54-56. 26  Louis J . west, "Psychopathology Produced by Sleep Deprivation," Sleep and Altered States of Consciousness (Baltimore: Williams & Uilkens Co., 1967), p. 537. 27  Sassin, "Neurological Findings," p. 56.  16 associated with increased t o t a l sleep time and a marked increase in the percentage of time spent i n the different stages of sleep. It uas found that on the f i r s t recovery night time spent i n IMREM sleep, especially stage 4, showed a marked increase.  On the other  hand, the percentage of REM sleep remained r e l a t i v e l y the same on the f i r s t recovery night but increased s i g n i f i c a n t l y on the fallowing nights.  This increase of time spent i n these two stages of sleep  i s accompanied, by a decrease i n the amount of IMREM stage 2 sleep. Therefore  the s t a b i l i t y of the basic ninety minute cycle i s pre28  served despite the increase i n one of the stages of sleep. The research on d i f f e r e n t i a l deprivation involved depriving subjects of some p a r t i c u l a r stage of sleep, for example depriving the i n d i v i d u a l of REM sleep.  Studies have shown that when REM sleep  was deprived i t caused a decreased onset and heightened l e v e l of REM sleep on the following night.  Other studies on deprivation of  Stage 4 sleep revealed there was a decreased latency and increased amount of Stage 4 sleep when the subjects returned to normal sleep patterns.  The s t a b i l i t y of the normal sleep pattern from night to  night and the r e s u l t s of these studies indicate that a constant per29 centage of REM and IMREM, stage 4, sleep i s needed each night. The vast amount of research into the function of sleep has revealed how l i t t l e we know. As Freeman states: 28 R. J . Berger and I. Oswald, "Effects of Sleep Deprivation on Behavior, Subsequent Sleep and Dreaming," Journal of Mental Science 108 ( A p r i l 1962): 457-65. 29 Uilse B. Webb, " P a r t i a l and D i f f e r e n t i a l Sleep Deprivation," Sleep; Physiology and Pathology, pp. 221-31. 1  i  ....such a complex phenomenon as s l e e p p r o b a b l y has many f u n c t i o n s , some n e u r o c h e m i c a l , some p s y c h o l o g i c , some o n t o g e n i c . 3 0 Postcardiotomy Psychosis As s t a t e d i n c h a p t e r one the i n c i d e n c e of p o s t o p e r a t i v e p s y c h o s i s i s h i g h e r i n open-heart to o t h e r s u r g i c a l patients."''''  surgical patients i n  comparison  Although t h e r e have been many f a c t o r s  i d e n t i f i e d as c o n t r i b u t i n g to i t s o c c u r r e n c e , t h e r e i s l i t t l e ment about the cause.  agree-  Abram i d e n t i f i e d such f a c t o r s as degree of  p r e o p e r a t i v e a n x i e t y , the use of d e n i a l as a defense mechanism and the f e a r of death as s i g n i f i c a n t i n the development of p s y c h o s i s 32 a f t e r open-heart  surgery.  i t s development a r e :  Other f a c t o r s t h a t may  c o n t r i b u t e to  age, s e v e r i t y of p r e o p e r a t i v e i l l n e s s , l e n g t h  and c o m p l e x i t y of the o p e r a t i v e p r o c e d u r e , time on  cardiopulmonary  bypass, sex, and l e n g t h a f s t a y i n i n t e n s i v e c a r e unit." '' 5  L a z a r u s and K a r n f e l d l o o k e d at the s i m i l a r i t y betueen the 34 35 symptoms of p o s t c a r d i o t o m y p s y c h o s i s and s l e e p d e p r i v a t i o n . '  ""Vreemon,  Sleep Research, p.  160.  "'"''Chase P. K i m b a l l , " P s y c h o l o g i c a l Responses t o Open-Heart S u r g e r y , " AORIM 12 (February 1970): 73. 32 Harry S. Abram, " A d a p t a t i o n t o Open-Heart S u r g e r y : A P s y c h i a t r i c Study t o the Threat of Death," The American J o u r n a l of P s y c h i a t r y 122 (December 1965): 659-67. American  "'"'p. H. B l a c h y and A l b e r t S t a r r , "Post-Cardiotomy D e l e r i u m , " J o u r n a l of P s y c h i a t r y 121 (October 1964): 371-75. 34  H. R. Lazarus and J . H. Hagens, " P r e v e n t i o n of P s y c h o s i s F o l l o u i n g Open-Heart S u r g e r y , " American J o u r n a l of P s y c h i a t r y 124 (March 1968): 1190-95. 35 Donald S. K o r n f e l d , " P s y c h i a t r i c C o m p l i c a t i o n s of C a r d i a c S u r g e r y , " I n t e r n a t i o n a l P s y c h i a t r i c C l i n i c s 4 (February 1967): 115-31  These symptoms included the f o l l o u i n g behaviors: disorientation, confusion, and paranoid  behavior.  depression,  acute excitement,  i l l u s i o n , hallucinations,  Also, another s i m i l a r i t y betueen the tuo  uas seen in the time sequence.  Kornfeld noted that the description  of the f i f t h day turning point in sleep deprivation studies uhen flagrant psychotic symptoms appear, closely p a r a l l e l the  clinical  experience in bath time af onset and rapid clearing uith adequate sleep. Environment of the Postcardiotomy Intensive Care Unit The environment of the intensive care unit i s one of the factors that contributes to postoperative patients." ^ 5  psychosis  DeMeyer intervieued tuenty-four  in open-heart  cardiac s u r g i c a l  patients to document their perception of their experience in the intensive care unit.  These patients spoke of the number of people  uho examined them or checked the equipment attached  to them, the  people uho talked about them uithout including them in the convers37 ation, and a general sense of urgency in the environment. •ther studies have supported these findings, that the stay in the intensive care unit i s a very disturbing experience.  The  en-  vironment i s described as one uhere patients are kept close to each other only separated "^Ibid., p.  by curtains and they are chained doun by uires 115.  37 JoAnna DeMeyer, "The Environment of the Intensive Care Unit," Nursing Forum k (October 1967): 263.  19 attached  to electrodes.  Also,there  are constant  and unusual sounds,  for example, the hissing of oxygen and the endless monitors.  c l i c k i n g of  They concluded that environmental factors made prolonged  uninterrupted  sleep impossible  for the adult i n the open-heart  intensive care unit." ^ 5  Another study at Temple University looked at interruptions sustained by these patients.  They stated the biggest deterent to  sleep uas the number of interruptions by nurses and physicians.  They  found that a l l patients suffer from some degree of sleep deprivation, 39 sensory over-stimulation  and human i s o l a t i o n .  These patients are c r i t i c a l l y i l l and do need constant observation follouing open-heart surgery.  Pitroak and Rae describe  the kind and type of nursing care that must be c a r r i e d out during this period.  Houever, they recommend along uith Kornfeld, Lazarus  and DeMeyer, that nursing procedures be geared to provide adequate sleep and rest, and to maintain the day-auake, night-sleep .. 40,41 ship. '  relation-  38 L. H. IMahum, "Madness i n the Recovery Room From OpenHeart Surgery or They Kept LJaking Me Up," Connecticut Medicine 29 (November 1965): 771. 39 "Intensive Care Gives Patients L i t t l e Rest," Journal American Medical Association 210 (December 1969): 1682. 40 Elizabeth P i t o r a k , " A l l e v i a t i n g Cardiac Patients' Fear Important Part of Nurses' Role," Hospital Topics 44 (May 1966): 127. 41 Nancy Mara Rae, "Caring for Patients Follouing Open-Heart Surgery," American Journal of Nursing 63 (November 1963): 77-82.  2D Existing Nursing Research Several nurse researchers have carried cut studies cn sleep deprivation follouing open-heart surgery.  Three studies have been  conducted at the University of [Washington.  E l u e l l , in 1967,  studied  duration of interruptions uhich i n i t i a t e d a c t i v i t y and the r e l a t i o n ship betueen their duration, the actual amount of sleep obtained, and the time available for sleep for four subjects 11:00 7:00  A.M.  In 196S,  P.M.  on their f i r s t , second and t h i r d nights follouing McFadden observed four postcardiotomy  to surgery.  subjects on their  fourth to sixth postoperative nights to determine i f they uere deprived of sleep.  Both investigators found indications of sleep de-  privation in their subjects.  The t h i r d study, in 1969,  out by three investigators, Garner, Hickman and Fugate.  uas carried They ob-  served four subjects for tuenty-four hours over eight postoperative days.  In addition, they looked at the number, frequency  and  char-  acter of p o t e n t i a l interruptions. The results shoued signs of sleep deprivation in their subjects.  In 1972,  Walker documented the  interactions sustained by four cardiotomy patients in the intensive care unit during an eight hour period for three consecutive days. Her study revealed a very high number of interactions for each patient.  Summary This chapter focused on the environment of the intensive care unit as one of the three main factors that contribute to postoperative psychosis.  It uas noted that there uas a s i m i l a r i t y betueen  21 the symptoms of sleep deprivation and postcardiotomy by several researchers.  Also, several studies recommended the  maintenance of the tuenty-four  hour sleep uakefulness cycle in  patients uho are nursed i n these areas. focused on the f o l l o u i n g :  psychosis  The l i t e r a t u r e revieu  (1) the 24-hour sleep-uakefulness  cycle,  (2) stages and patterns of sleep, (3) sleep deprivation, (4) postcardiotomy psychosis, and (5) the environment of the open-heart i n tensive care unit. Researchers had noted that interruptions by doctors and nurses uere the biggest deterrent to sleep.  In revieuing existing  research there appeared to be a lack of available studies on the type and frequency of interruptions experienced by patients i n postcardiotomy intensive care u n i t s .  CHAPTER III METHODOLOGY Introduction This study uas designed as a descriptive survey to c o l l e c t data on the type and frequency of interruptions sustained by postcardiotomy patients i n an intensive care unit. follouing u i l l be discussed:  In this chapter the  adaptation and content of the t o o l ,  the setting and patient care a c t i v i t i e s of the intensive care unit, the p i l o t study, the sample and method of c o l l e c t i n g data. Adaptation of the Tool The farm used i n this survey uas a checklist of interrupting activities. study.  It uas adapted from the one used by Garner i n her  Adaptation uas accomplished by revieuing the.form i n the  l i g h t of pertinent information found i n the l i t e r a t u r e , u t i l i z i n g the routine nursing care procedures of the hospital setting uhere the study uas carried out, having the form revieued by senior nurses uho uark i n a postcardiotomy intensive care unit and then by testing the form during the p i l o t study.  The result of these procedures  indicated the tool had content v a l i d i t y . Checklist of Interrupting A c t i v i t i e s The checklist of interrupting a c t i v i t i e s used for c o l l e c t i n g the data i s found i n Appendix A.  Bath the content and the order of  22  23 the checklist underwent change from the form used by Garner.  The  changes were made to add items that mere pertinent to the purpose of the study and to delete ones that uere not.  A change i n the  order of a c t i v i t i e s uas made for p r a c t i c a l i t y and ease of use. Also, because continuous observations uere pertinent to the study a different format uas used.  At the top of the form a space uas  provided to note the date, time and postoperative day of the patient. To f a c i l i t a t e the analysis of the data the types of a c t i v i t i e s uere organized under four categories (Appendix B, page 55 ): 1.  Nursing a c t i v i t i e s included any interruptions by a  nurse i n giving care either i n direct contact or i n d i r e c t contact uith the patient. These a c t i v i t i e s uere grouped according to the kind of nursing care; that i s :  (a) measures to provide comfort, (b) mon-  i t o r i n g measures, (c) measures to support r e s p i r a t i o n , (d) c i r c u l a t i o n , (e) n u t r i t i o n and elimination, and ( f ) nurse uith patient.  communicating  The l a t t e r refers to interruptions i n i t i a t e d by the  nurse talking d i r e c t l y to the patient uhen no other a c t i v i t y uas apparent. 2.  Patient i n i t i a t e d a c t i v i t i e s included any interruptions  that uere i n i t i a t e d by the patient, uithout any other apparent provoking stimulus. 3.  A c t i v i t i e s of others included any interruptions by any  individual other than a nurse. U.  Environmental a c t i v i t i e s included any interruption by  an i n d i v i d u a l or thing not related to the care of the patient.  2k The Setting The setting i n uhich the study took place uas the pastcardiatDmy intensive care unit o f a  2,000 bed h o s p i t a l .  The inten-  sive care unit uhich can accommodate tuelve patients consists of one area u i t h ten patient care units and another area u i t h tuo patient care units. The area containing the ten units provided the setting i n uhich the observations uere made. u i t h a jog at one end.  This area i s rectangular i n shape  There are doors at each end and tuo doors  that open into a corridor uhich runs along the length o f one side of the u n i t .  The unit i s partitioned o f f u i t h s i x patient care units  on one side and four patient care units on the other side of the partition. unit. units.  There are tuo nursing stations, one at each end of the  The main station i s at the end of the area u i t h the s i x care At the other end just o f f from the nurses' station uas a  dirty u t i l i t y  area u i t h a hopper sink.  Eight patient care units  are side by side and face a rou of windows.  The other tuo care units  are i n the area of the jog and face i n the apposite direction t a uards the main nurses' s t a t i o n . Each care unit i s approximately one.  four feet from the adjoining  Every unit has a monitor over the head of the bed, under uhich  a Mark UII Bird Respirator i s mounted on the u a l l . the u a l l i s a sphygmomanometer.  Also mounted on  An intravenous pole on a track i s  on the c e i l i n g directly over the patient's bed.  There are four  drawers for supplies and patients' belongings b u i l t into the u a l l for each unit. and underuater  Also, oxygen, suction and compressed a i r outlets chest suction are part of the i n d i v i d u a l patient  25 units. The unit i s a neutral color uith uhite walls and c e i l i n g , gold curtains betueen care units and a tan f l o o r . uhite uniforms.  The nurses uear  Light for the patient care areas i s provided by a  large, s e t - i n , c e i l i n g l i g h t , the intensity of uhich uas varied independently for each unit.  Additional l i g h t comes from the  nurses' station and u t i l i t y area. Patient Care A c t i v i t i e s Since the number of interruptions depended partly ,on the nursing care these patients received, the usual routines u i l l be b r i e f l y described. •n the operative day and then as long as their condition dictated, postcardiotomy patients uere the sole r e s p o n s i b i l i t y of one registered nurse.  Uhen their condition improved the patients shared  a nurse uith one or more other patients. The immediate postoperative care of these patients included a v i t a l signs check every five minutes for several readings on admission to the area.  After the f i r s t readings the v i t a l signs uere  checked every f i f t e e n minutes u n t i l stable, then every t h i r t y minutes for the f i r s t eight hours.  Then they uere reduced to every  hour and after t h i r t y - s i x hours they uere taken every tuo hours. The temperature uas taken every f i f t e e n to t h i r t y minutes normal, and then every tuo hours.  until  Also, an hourly central venous  pressure uas taken and a head to toe check three times a s h i f t , uhich included:  pupils, limb movement, l e v e l of consciousness, color,  chest expansion, breath sounds, abdomen and pedal pulses. Other a c t i v i t i e s included: hourly stripping of chest tubes,  nasotracheal suctioning, measuring urine output and any additional care or therapy indicated by the patient's condition.  Continuous  oxygen by mask uas given for the f i r s t three postoperative days. As the patient progressed the amount of care uas adjusted accordingly. Specimens for blood gases, hemoglobin and serum electrolytes and a chest x-ray uere taken on return from the operating room and every morning for the f i r s t three postoperative days. E.C.G. tracings uere taken on admission to the intensive care unit after surgery and then once a s h i f t for forty-eight hours and then as necessary. The patient usually returned from the operating room uith an endotracheal tube, an intravenous catheter, a r t e r i a l catheter, central venous pressure l i n e , tuo chest tubes and a Foley catheter. Each one of the tubes  i s removed as soon as possible. The P i l o t Study  To test the adapted observational t o o l , to check for pract i c a l i t y and ease of use of the t o o l , to check observer  reliability,  to determine the best location for the observer to carry out her study and to determine the f e a s i b i l i t y of observing continuously for a period of time, a tuo-hour p i l o t study uas conducted observer and another master's student i n nursing. uas a period from 9:00 A.M. to 11:DD A.M.  by the  The time chosen  I t uas f e l t that this  uould be a time uhen many a c t i v i t i e s uould.be occurring. The results of the p i l o t study uere as f o l l o u s .  In the  f i r s t half hour of the tuo-hour p i l o t study there uas 95 percent agreement betueen the observers regarding the types of interruptions.  27 Uith regards to the frequency of interruptions the r e s u l t s of one observer uas six minutes of no interruptions, uhereas the second observer noted eight.minutes of no interruptions.  Houever, the  last hour and one-half there uas 100 percent agreement betueen the observers both in the types and frequency of interruptions.  It  uas f e l t by the tuo observers that the discrepancy in the r e s u l t s of the f i r s t t h i r t y minutes of observation may  have been due to  the observers' unfamiliarity uith the checklist  itself.  The results of the P i l o t Study indicated that i t uas feasible to observe for a four-hour period and that there uere feu i n t r a observer differences i n the recording. The Sample The sample included 108 hours of observation uhich uere divided into tuenty-seven four-hour blocks. uere: 2:00 10:00  2:00 A.M., A.M.  P.M. 2:00  - 6.00 A.M.  - 2:00  P.M.,  - 6.00  P.M.  6:00 A.M.,  P.M. 6:00  The four-hour blacks  - 10:00 A.M.  P.M.,  - 10:00  10:00 A.M.,  P.M.  -  and  These time blocks uere chosen because most  patients returned from the operating roam betueen 12:00 2:00  P.M.  M. and  It uas decided that the observation for the f i r s t past-  operative period could begin at 2:00  P.M.  The time postoperatively  uas also taken into consideration because of the change in patients' condition i n the f i r s t feu days.  It uas decided to look at post-  operative time in an early period, zero to sixteen hours, a middle period, sixteen to t h i r t y - s i x hours, and a late period, t h i r t y - s i x to f i f t y - s i x hours. six  In each postoperative period there uere t h i r t y -  hours of observations.  A random sampling of the four-hour time  blocks i n each postoperative period over the days of the ueek uas  28 carried cut and can be seen i n Appendix C, page 57 . Adult patients uho had surgery uhere the cardiopulmonary bypass machine uas used uere observed.  Children uere eliminated  from the study because the incidence of postoperative psychosis i s rare i n their cases.* Collection of the Data Before beginning the study a resume of the study uas sent to the Acting Director of IMursing v i a the l i a i s o n person betueen the university and the h o s p i t a l .  The investigator received u r i t t e n  permission to carry out the study.  The unit supervisor uas contacted  and she put the investigator i n touch uith the head nurse of the postcardiotomy intensive care unit. IMurses uorking i n the area uere informed about the purpose of the study at a s t a f f meeting.  Also individual nurses caring f o r  patients being observed uere asked at each observation time i f they uould object to the investigator observing their patient. The Human Rights Committee at the University uere also sent a resume of the study.  As the study did not f a l l under the j u r i s -  diction of this committee,  the investigator could begin her observ-  ations. Permission from i n d i v i d u a l patients uas not obtained because there uas no invasion of the patient's privacy or r i s k involved. Also, no record of names uas kept and the routine care uas not  *Donald S. Kornfeld, Sheldon Zimberg, and James R. Malm, "Psychiatric Complications of Open-Heart Surgery," The IMeu England Journal of Medicine 273 (August 1965): 292.  29  altered  i n any u a y . All  o b s e r v a t i o n s over  investigator. ten  t h e 108 h o u r s  The i n v e s t i g a t o r  arrived  r e c o r d e d by t h e  at the area  minutes b e f o r e t h e hour t h e o b s e r v a t i o n s uere  gave h e r t i m e  the sample.  approximately  to begin.  t o s e l e c t t h e p a t i e n t uho u a s t o be o b s e r v e d ,  t h e p a t i e n t uho u a s i n t h e p a r t i c u l a r  to  uere  The i n v e s t i g a t o r  vieu the p a t i e n t without  This that i s ,  p o s t o p e r a t i v e time p e r i o d o f  s t a t i o n e d h e r s e l f uhere she uas a b l e  interfering  uith  t h e u n i t made i t i m p o s s i b l e f o r t h e o b s e r v e r  care.  The d e s i g n o f  t o be o u t o f t h e l i n e o f  v i s i o n of the patient. A uatch u i t h  a second  hand was u s e d f o r t h e m i n u t e by m i n u t e  o b s e r v a t i o n a n d was s e t a t t h e same t i m e The  o b s e r v a t i o n began as t h e second  mark o f t h e f i r s t  as t h e c l o c k i n t h e u n i t .  hand was a t t h e t u e l v e o ' c l o c k  minute o f the f i r s t  hour.  r e c o r d e d on t h e c h e c k l i s t o f a c t i v i t i e s  Each o b s e r v a t i o n uas  f o r every minute over the r  four-hour reached of  period.  The o b s e r v a t i o n p e r i o d e n d e d u h e n t h e s e c o n d  t h e t u e l v e o ' c l o c k mark o f t h e f i r s t  the f i f t h  hour.  A l l o b s e r v a t i o n s uere  hand  minute o f the beginning  completed  i n a six-ueek  period. Summary  This chapter included:  the methodology o f the study  t h e a d a p t a t i o n and c o n t e n t o f t h e t o o l ,  the s e t t i n g  and p a t i e n t c a r e a c t i v i t i e s  t e n s i v e care u n i t , method o f d a t a  i  has p r e s e n t e d  a resume o f t h e p i l o t  collection.  uhich  a description of  of the postcardiotomy i n s t u d y , t h e sample and t h e  CHAPTER IV ANALYSIS DF THE DATA Presented i n t h i s chapter are the data obtained by the method described i n Chapter I I I .  Answers were sought to the following  questions: 1.  How frequent are the interruptions experienced by  these patients? 2.  How long are the blocks of uninterrupted time?  3.  Uhat are the types of interruptions? Presentation of Findings Frequency of Interruptions  Table 1 indicates the average time between interruptions i n the four hour blocks within the three postoperative periods.  The  early postoperative period had the longest average time between interruptions, that i s , one interruption occurring every 2.43 minutes.  In the mid and late postoperative period the average times  between interruptions were almost i d e n t i c a l , 1.97 and 1.95 minutes respectively. However, the greatest average time between interruptions i n the four hour time blocks was between 2:00 A.M. to 6:00 A.M., 3.02 minutes i n the early postoperative period and 3.33 minutes i n the late postoperative period.  The lowest average time between i n t e r 30  31 TABLE 1 AVERAGE TIME IN MINUTES BETWEEN INTERRUPTIONS IN THE FOUR-HOUR TIME BLOCKS IN EACH POSTOPERATIVE PERIOD Average Time in Minutes Betueen Interruptions Time Blocks  Early Postoperative Period  Mid Postoperative Period  Late Postoperative Period  2-6 P.M.  2.65  1.47  1.38  6-10 P.M.  2.00  1.60  1.63  10-2  2.OS  2.65  • • •  2-6 A.M.  3.02  • • •  3.33  6-10 A.M.  • • •  1.94  2.01  10-2  • • •  2.18  1.40  2.43  1.97  1.95  A.M.  P.M.  Period Average  a  No observations made. ruptions uas 1.38 minutes i n the late postoperative period betueen 2:00 P.M. and 6:00 P.M. Length of the Blocks of Uninterrupted Time Findings relevant to the second question regarding the length of the uninterrupted time blocks are shoun i n Table 2. reveal  The data  that there are no uninterrupted time blocks of over f i f t y  minutes i n any postoperative period.  The early postoperative period  has tuo uninterrupted time blocks of forty-one to f i f t y minutes i n length.  In the mid and late postoperative periods the longest blocks  32 TABLE 2 NUMBER AND DURATION OF UNINTERRUPTED TIME BLOCKS IN THE THREE POSTOPERATIVE PERIODS Number of Uninterrupted Time Blocks Early Postoperative Period  Duration 5 mins. or less  213  Mid Postoperative Period  Late Postoperative Period  181  Total  185  579  27  89  6 to 10 mins.  36  26 .  11 to 20 mins.  14  21  . 14  49  21 to 30 mins.  7  3  3  13  31 to 40 mins.  1  2  1  . 4.  41 to 50 mins.  2  0  0  2  over 50 mins.  0  0  0  0  of uninterrupted time uere thirty-one to forty minutes.  The greatest  t o t a l number of uninterrupted time blocks i n a l l three postoperative periods uere f i v e minutes or less i n length. The average number and length of uninterrupted time blocks in each four-hour time block are shoun i n Table 3. Averages uere computed for t h i s table because there uere unequal numbers of the four-hour blacks i n the three postoperative periods.  The t o t a l  number and duration of uninterrupted time blocks f o r a l l the fourhour time blocks are shoun i n Appendix D.  The shortest uninterrupted  time blocks uere betueen 2:00 P.M. and 6:00 P.M. i n the mid postoperative period, uith no blocks longer than ten minutes.  33 TABLE 3 AVERAGE NUMBER AND DURATION OF THE UNINTERRUPTED TIME BLOCKS IN THE FOUR-HOUR BLOCKS IN THE THREE POSTOPERATIVE PERIODS Average Number of Uninterrupted Time Blocks Duration  Four Hour Time Blocks 2-6 P.M.  6-lD P.M.  10-2 A.M.  2-6 A.M.  6-10 A.M.  10-2 P.M.  Early Postoperative Period 5 mins. or less 6 to 10 mins. 11 to 20 mins. 21 to 3D mins. 31 to 40 mins. 41 to 50 mins. aver 50 mins.  25.0 4.5 l.D 1.0 D .5 D  25.D 4.D 2.0 .5 0 D 0  24.3 3.3 .66 l.D D .33 D  2D.0 4.D 3 .5 .5 D 0  a  •• •  ...  ... ... •• • ...  Mid Postoperative Period 5 mins. or less 6 to 10 mins. 11 to 2D mins. 21 to 30 mins. 31 to 40 mins. 41 to 50 mins. over 50 mins.  29.D 3.D 0 D D D 0  22.5 .5 1.0 1.0 D D 0  19.5 4.5 3.5 .5 D 0 D  18.5 2.D • • o 2.5 • mo D •• • l.D •• • 0 D •• •  ...  15.5 4.5 3.5 D D D D  Late Postoperative Period 5 mins. or less 6 to 10 mins. 11 to 2D mins. 21 to 30 mins. 31 to 4D mins. 41 to 5D mins. Dver 5D mins.  16.D 2.D l.D .5 .5 0 0  No observations made.  22.33 3.33 1.33 D D D D  ... ... ... ... ... ... ...  15.D 5.D 2.D 2.D D D D  21.0 3.D 4.D D D D D  23.0 2.D 1.0 D D 0 D  34 Types of Interruptions Tables 4 and 5 show the types of interruptions i n each of the three postoperative periods. The data i n Table 4 reveal  that the t o t a l number of i n t e r -  ruptions increases over the three postoperative periods.  The greatest  t o t a l number of interruptions i n a l l three periods uas the result of nursing a c t i v i t i e s .  Environmental  highest, with the greatest frequency  interruptions uere the second i n the mid postoperative period.  TABLE 4 NUMBER AND PERCENTAGE OF INTERRUPTIONS IN EACH CATEGORY UITHIN THE THREE POSTOPERATIVE PERIODS Number and Percentage of Interruptions  Category  Early Postoperative Period  Mid Postoperative Period  Late Postoperative Period  No.  %  No.  %  No.  %  Nursing activities  644  58  568  43  769  50  Patient initiated activities  126  11  135  10  233  15  Activities of others  102  9  283  22  269  17  Environment  24S  22  334  25  262  18  Total  1,120"  100  1,320  100  1,533  100  35 TABLE 5 NUMBER QF INTERRUPTIONS IN THE TYPES OF ACTIVITIES IN THE THREE POSTOPERATIVE PERIODS Number of Interruptions Types of Activities Nursing  Early Postoperative Period  Mid Postoperative Period  139  195  270  226  166  216  74  68  76  . 12S  55  50  12  48  105  65  36  52  Gkk  568  769  126  135  233  26 16  ka  38 20 2 5 10 208  41 4 4 38 5 177  102  283  269  109 6 11 115 7  144 5 10 163 12  109 2 14 129 8  ZkB  334  262  Late Postoperative Period  activities  Comfort measures Monitoring measures Circulation measures Respiration measures Nutrition and elimination measures Nurse communicating uith patient Total Patient i n i t i a t e d activities A c t i v i t i e s of others Personal v i s i t o r s Doctor Housekeeping Laboratory X-ray. Physiotherapist Total  • • •  5 7  Environment Noise Lights Telephone Talking Monitor alarm 1  Total  I  36 Tables 6 to 8 contain a further breakdown of the types of interrupting a c t i v i t i e s .  Each category i n these tables i s represented  as 100 percent and the types of a c t i v i t i e s were calculated as a percentage of the t o t a l . Data from Table 6 show the percentage of interruptions by types of nursing a c t i v i t i e s .  In the three postoperative periods  comfort and monitoring were responsible for over 55 percent of the interruptions. The percentage of interruptions by others i s indicated i n Table 7.  In a l l three postoperative periods the physiotherapist was  responsible for the greatest number of interruptions.  However, types  of interruptions by others were only responsible for 9 percent, 22 percent and 17 percent of the t o t a l number of interruptions i n the early, mid and late postoperative periods respectively (see Table 4). Environmental interruptions as shown i n Table 8 reveal that noise and talking were responsible for over 90 percent of these ruptions i n a l l three postoperative periods.  inter-  As indicated i n Table 1  environmental factors were the second most frequent type of i n t e r ruption. The data i n Table 9 show the average number of interruptions in the four categories of a c t i v i t y for the different times of day. IMursing a c t i v i t i e s increased over the postoperative period between 2:00 P.M. to 6:00 P.M.  However, in the 10:00 P.M. to 2:00 A.M. and  the 2:00 A.M. to 6:00 A.M. time blocks, nursing a c t i v i t i e s as postoperative time increased.  decreased  Patient i n i t i a t e d a c t i v i t i e s i n -  creased over the postoperative period.  This increase i s what would  be expected i n a normal.postoperative recovery course.  Environmental  37 TABLE 6 PERCENTAGE OF INTERRUPTIONS BY TYPES OF NURSING ACTIVITIES IN THE THREE POSTOPERATIVE PERIODS Types of Nursing Activities  Percentage of Interruptions Early Postoperative Period  Mid Postoperative Period  Late Postoperative Period  Comfort measures  21.5  34  35  Monitoring  35  29  28  Circulation  11.5  12  10  Respiration  20  10  2  9  10  6  100  100  Nutrition and Elimination Nurse Communicating uith Patient Total  6.5 14 6.5 100  TABLE 7 PERCENTAGE OF INTERRUPTIONS BY ACTIVITIES OF OTHERS IN THE THREE POSTOPERATIVE PERIODS~ Activities of Others  Percentage of Interruptions Early Postoperative Period  Mid Postoperative Period  Late Postoperative Period  Personal v i s i t o r s  25  13  Doctor  16  7  1.5  Housekeeping  0  1  1.5  Laboratory  5  2  14  X-ray  •7  4  2  un  73  66  100  100  100  Physiotherapist Total  15  38 TABLE 8 PERCENTAGE DF INTERRUPTIONS BY ENVIRONMENTAL ACTIVITIES IN THE THREE POSTOPERATIVE PERIODS Percentage of Interruptions Environment  Noise  Early Postoperative Period 44  Mid Postoperative Period 43  Late Postoperative Period 42  Lights  2.5  1.5  1  Telephone  4.5  3  5  49  49  Talking Monitor alarm Total  46 3 100  3.5 100  2 100  39 TABLE 9 AVERAGE NUMBER DF INTERRUPTIONS IN THE CATEGORIES OF ACTIVITY IN THE FOUR-HOUR BLOCKS IN THE THREE POSTOPERATIVE PERIODS Average Number of Interruptions Category of Activity  Four -Hour Blocks 2-6 P.M.  6-10 P.M.  10-2 A.M.  2-6 A.M.  6-10 A.M.  10-2 P.M.  Early Postoperative Period Nursing  71.5  Patient Initiated  10  Others Environment  80.5  75  57.5  8  14.6  19.5  28  6.5  23  a •• •  •• •  23  •• •  • • •  1.6  1  • • •  • • •  57.6  a  • • •  • • ••  Mid Postoperative Period Nursing  B9  108.5  Patient  7  36.5  •• •  55.5  38  5.5  26  •• •  11  21.5  20.5  •• •  40.5  49.5  28  •• •  40  21.5  Others  52  5  Environment  43  57  Late Postoperative Period 121  Nursing  88.6  • • •  37  52  93  Patient Initiated  23.5  18.6  • • *  49  20  30.5  Others  37  21.6  •• •  1  40  37.5  Environment  11  43.6  • • •  10  29  °35  No observations made.  40 interruptions uere the highest i n most of the time blocks i n the mid postoperative period. Discussion of the Findings The findings that emerged as s i g n i f i c a n t i n this study (1) that patients i n postcardiotomy  uere:  intensive care units uere i n t e r -  rupted so frequently that there uas l i t t l e time available for rest and sleep, and (2) nursing care a c t i v i t i e s uere responsible far the greatest number of these interruptions. These findings were similar to the findings of other studies carried out i n postcardiotomy  intensive care units by Kornfeld and  Lazarus. Patients can not sleep i f they are constantly interrupted. The data i n Table 1 demonstrate that the frequency  of interruptions  in a l l time blocks over the three postoperative periods was high. The range for the t o t a l postoperative period was from one interruption occurring every 1.40 minutes to one interruption occurring every 3.33 minutes.  The frequency  of interruptions noted i n t h i s study  seemed to r e f l e c t the tendency of postcardiotomy units to provide continued care without 24-hour sleep-wakefulness  intensive care  regard to time of day and the  cycle.  In order to complete one sleep cycle an adult requires approximately eighty-five to ninety minutes of uninterrupted rest."''  The  data i n Table 2 reveal there are no uninterrupted time blacks over f i f t y minutes i n any of the postoperative periods.  These findings  "''Nathaniel Kleitman, Sleep and wakefulness University of Chicago Press, 1963), p. 91.  (Chicago:  indicated that there uas no time available to patients far periods of prolonged, uninterrupted r e s t . fifty-six  Therefore, patients i n the f i r s t  hours postoperatively uere unable to complete one sleep  cycle because of the constant interruptions. Also, the data suggested that patients uere t o t a l l y deprived of REM sleep.  As noted previously, i n Chapter 2, REM sleep  is the stage uhen a person i s ascending from Stage 2 to Stage 1. This stage of sleep occurs approximately after seventy minutes of sleep. is vital  As mentioned i n the l i t e r a t u r e revieu each stage of sleep and necessary.  These findings suggested that patients uere  not meeting their physiological need for sleep i n the f i r s t six  fifty-  hours postoperative i n a postcardiotomy intensive care u n i t . Three studies from the University of Washington by E l u e l l ,  McFaddin and Garner found that patients i n an intensive care unit follouing open-heart surgery uere deprived of sleep. Studies have indicated that intensive nursing and medical care i s the biggest deterrent to sleep i n the open-heart 2 unit.  The data i n Table H support these findings.  intensive care Nursing a c t i v -  i t i e s uere the most frequent source of interruptions f o r a l l three postoperative periods. The next most frequent a c t i v i t i e s uere environmental.  Talking  among the hospital personnel and noise together t o t a l 90 percent of these interruptions.  Although i t uas beyond the scope of t h i s  study to document i n d e t a i l the cause of the noise the investigator 2 Donald S. Kornfeld, Shelden Zimberg, and James R. Malm, "Psychiatric Complications of Open-Heart Surgery," The Neu England Journal of Medicine 273 (August 1965): 291.  42 did note some of the s p e c i f i c noises. as:  These included such things  respirators c l i c k i n g , hoppers flushing, blinds snapping,  addressograph banging* pounding  battle on the f l o o r ,  restocking  drawers, emptying garbage p a i l s , whistling of housekeepers and doors slamming.  By c o n t r o l l i n g these environmental interruptions  the t o t a l number of interruptions might be decreased on an average by 22 percent.  As noted e a r l i e r i n Chapter 1, postcardiotomy  patients complained of the noisy environment of the intensive care unit. Summary This chapter presented the findings of the study and °the discussion of those findings.  The data were analyzed i n the l i g h t  of the three questions posed i n the statement of the problem.  o  CHAPTER V SUMMARY, IMPLICATIONS AND RECOMMENDATIONS FOR NURSING CARE, AND RECOMMENDATIONS FOR FURTHER INVESTIGATION Summary The incidence of postoperative psychosis follouing openheart surgery, as reported in the l i t e r a t u r e , i s quite high.  One  of the possible contributing factors uhich has been cited i s the environment of the intensive care u n i t .  Postcardiotomy patients  have complained about the noisy atmosphere and the lack of sleep during their stay in the intensive care unit.  Several researchers  have noted the s i m i l a r i t y betueen those symptoms of sleep deprivation and postcardiotomy in the postcardiotomy  psychosis.  The biggest deterrent to sleep  intensive care unit i s attributed to the number  of interruptions by nursing and medical  personnel.  The purpose of this study uas to document the type frequency  of interruptions sustained by postcardiotomy  an intensive care unit.  To accomplish  and  patients in  t h i s , the data uere collected  by the investigator u t i l i z i n g a non-participant checklist of i n t e r rupting a c t i v i t i e s .  The sample included 108 hours of observation  covering the f i r s t f i f t y - s i x postoperative hours, divided into early, mid and late postoperative periods.  In each postoperative period  there uere t h i r t y - s i x hours of observation.  To f a c i l i t a t e contin-  uous observation the observation periods uere divided into four-  43  44  hour blocks, for example, 2:00 P.M. to 6:00 P.M.  A random samp-  ling of the four-hour blocks i n each postoperative period over the days of the ueek uas carried out to ensure unbiased  selection.  A revieu of the l i t e r a t u r e focused on the environment of the postcardiotomy  intensive care unit uhich i s considered to be  one e t i o l o g i c a l factor of postcardiotomy  psychosis.  A descriptive analysis of the data collected centered around the three questions posed i n the statement of the problem. The questions related to the length of the uninterrupted time blocks and the frequency and types of interruptions. In order to f a c i l i tate the analysis of the data the types of interruptions uere organized into four main categories:  (1) nursing a c t i v i t i e s ,  (2) patient i n i t i a t e d a c t i v i t i e s , (3) a c t i v i t i e s of others, and (4)  environment. The data regarding the frequency of interruptions indicate  the t o t a l average time betueen interruptions i s 2.12 minutes f o r the entire observation period.  Also, the greatest length of aver-  age time betueen interruptions i s only 3.33 minutes, recorded betueen 2:00 A.M. and 6:00 A.M. i n the late postoperative period. There are no uninterrupted time blacks over f i f t y minutes in the three postoperative periods.  In the t o t a l observation there  are tuo blocks of uninterrupted time, forty to f i f t y minutes long. Houever, both of these blocks occur during the day. The data show, that the number of interruptions increased from the early postoperative period to the late postoperative period from 1,120 to 1,533.  IMursing a c t i v i t i e s constituted the  highest number of interruptions. Percentage of the t o t a l number of  45 interruptions i n each category for the IDS hours of observation i s shoun as fallows: Category af Interruptions  Percentage  IMursing A c t i v i t i e s  50  Patient I n i t i a t e d A c t i v i t i e s  12  A c t i v i t i e s of Others  16  Environment  22  The conclusions  that can be made from these findings are that  patients i n the postcardiotomy intensive care unit are frequently interrupted and there i s very l i t t l e time available for rest and sleep. Implications and Recommendations for IMursing Care Nurses have the r e s p o n s i b i l i t y for helping patients meet their physiological need for sleep.  Also, several studies have  recommended that nurses i n postcardiotomy intensive care units r e organize  their care to maintain the patient's day-awake and night-  asleep cycle.  Intensive care nursing requires that the patients  be interrupted more than patients who are not i n intensive care units.  Houever, nurses should be able to provide adequate care i n  these areas and s t i l l help the patient meet need by reducing  h i s i n d i v i d u a l sleep  the number of interruptions.  Some recommendations to implement this aspect of care are: 1. corporate 2.  Nursing care plans i n intensive care units should i n the patient's need for sleep. Nursing h i s t o r i e s should include the patient's sleep  46 pattern to maintain the usual day-awake and night-asleep cycle. 3.  Reorganization of routine nursing procedures  such as  v i t a l signs to allow for a maximum amount of uninterrupted time for  rest and sleep. 4.  Nurses should educate other hospital personnel to the  patient's need for sleep and include them i n planning care to allow for maximum rest periods. 5.  Nurses should be aware of the impact of environmental  stimuli on the completion  of the sleep cycle and their role i n con-  t r o l l i n g them. Recommendations for Further Investigation The findings of t h i s study suggest other studies which might be carried out: 1.  A similar study might be designed u t i l i z i n g twD or  three investigators to obtain data over a twenty-four  hour period  for the entire postoperative stay i n the open-heart intensive care unit. 2.  A study might be done to further analyze the environ-  mental stimuli i n .the postcardiotomy 3.  intensive care unit.  An experimental study u t i l i z i n g a different approach  to organizing nursing care to allow the patient a maximum amount of uninterrupted time for rest and sleep.  BIBLIOGRAPHY A. Books Colquhoun, LI. P. ed. Aspects of Human E f f i c i e n c y : Diurnal Rhythm and Loss of Sleep. London: Universities Press, 1972. Freemon, Frank R. Sleep Research; A C r i t i c a l Revieu. Charles C. Thomas, 1972. Kales, Anthony. Sleep, Physiology and Pathology. Toronto: J . B. Lipincott Co., 1969. Kleitman, Nathaniel. Sleep and Wakefulness. Chicago Press, 1963.  Illinois:  Philadelphia and  Chicago:  University of  Leuis, Edith P., comp. IMursing i n Cardiovascular Diseases. American Journal of IMursing Co., 1971. Murray, Edward J . Sleep, Dreams and Arousal. >TJentury-Crofts, 1965.  New York:  IMeu York: Appletan-  Oswald, Ian. Sleeping and Waking; Physiology and Psychology. Amsterdam: Elsevier Publishing Co., 1962. Webb, Wilse B. Sleep; An Experimental Approach. Co., 1968.  New York:  Macmillan  Sleep and Altered States of Consciousness. Association for Research in Nervous and Mental Disease. Baltimore: Williams and Wilkins, 1967. B. Periodicals  Abram, Harry S. "Adaptation to Open-Heart Surgery: A Psychiatric Study of Response to the Threat of Death." The American Journal of Psychiatry 122 (December 1965): 659-67. Aiken, Linda H., and Henrichs, Theodore F. "Systematic Relaxation As A Nursing Intervention With Open-Heart Surgical Patients." Nursing Research 20 (May-June 1971): 212-16. Aschoff, Jurgen. "Circadian Rhythms in Man." 1965): 1427-32. 47  Science 148:  (June  48 Aserinsky, E., and Kleitman, IM. "Tuo Types'of Occular M o t i l i t y Occurring in Sleep." Journal Applied Physiology 8 (July 1955): 1-10. Beland-Marchak, Nicole. "Circadian Rhythm." (December 1968): 40-44.  Canadian Nurse 64  Berger, R. J . and Oswald, I. "Effects of Sleep Deprivation on Behavior, Subsequent Sleep and Dreaming." Journal of Mental Science 108 (July 1962): 457-65. Blacher, R. S. "The Hidden Psychosis of Open-Heart Surgery." Journal American Medical Association 222: (October 1972): 305-8. Blachy, P. H. and Starr, Albert. "Post-Cardiotomy Delerium." American Journal of Psychiatry 121 (October 1964): 371-75. Briggs, Louise U., and Mortensen, J . D. "Nursing Care of the Patient uith a Prosthetic Heart Valve." American Journal of Nursing 63 (October 1963): 66-70. Conroy, R.T.lil.L. "Jet Travel and Circadian Rhythms." Nursing Times 68 (March 1972): 370-72. Dammann, Francis J.; Thung, Nalda; C h r i s t l i e b , Ianacio I.; L i t t l e f i e l d , James B.; and M i l l e r , Uilliam H. J r . "The Management of the Severely 111 Patient After Open-Heart Surgery." Journal of 'Thoracic and Cardiovascular Surgery 45 (January 1963): 80-90. Dement, U i l l i a m C.,. and Clemes, Stanley R. "Effects of REM Sleep Deprivation on Psychological Functioning. Journal of Nervous and Mental Diseases 144 (June 1967): 485-91. 11  Dement, U. C , and Kleitman, N. "Cyclic Variations i n E.E.G. During Sleep and Their Relation to Eye Movement, Body M o t i l i t y and Dreaming." Electroencephlogaphy and C l i n i c a l Neurophysiology 9 (November 1957): 673-90. DeMeyer, JoAnna. "The Environment of the Intensive Care Unit." Nursing Forum 6 (October 1967): 262-72. Egerton, N., and Kay, J.H. "Psychological Disturbances Associated uith Open-Heart Surgery." B r i t i s h Journal of Psychiatry 110 (May 1964): 433-39. Feinberg, I., and Carlson, V.R. "Sleep Variables as a Function of Age i n Man." Archives of General Psychiatry 18 (February 1968): 239-50. Felton, Geraldene. "Effects of Time Cycle Change on Blood Pressure and Temperature i n Young Uomen." Nursing Research 19 (JanuaryFebruary 1970): 48-58.  49 Hacket, Thomas P.; Cassem, N.H.; Whishnie, Howard A. "Coronary Care Unit. An Appraisal of i t s Psychological Hazards." The New England Journal of Medicine 279 (December 1968): 1365-70. Hartmann, E. "The 90-Minute Sleep-Dream Cycle." Psychiatry 18 (March 1968): 280-86.  Archives of General  Haslam, Pamela. "Noise i n Hospitals: Its Effect on the Patient." Nursing C l i n i c s of North America 5 (December 1970): 715-24. Jouvet, M. "Neurophysiology of the States of Sleep." Reviews 47 (January 1967): 117-65.  Physiological  Karacan, Ismet; Williams, Robert L.; Finley, William W.; and Hursch, Carolyn J . "The Effect of Naps on Nocturnal Sleep: Influence on the Need for Stage 1 REM and Stage 4 Sleep." B i o l o g i c a l Psychiatry 1-2 (October 1970): 391-99. Kimball, Chase P. "Psychological Responses to Open-Heart Surgery." AORN 12 (February 1970): 73-84. Klein, K.E.; Wegmann, H.M.; and Bruner, H. "Circadian Rhythm i n Indices of Human Performance, Physical Fitness and Stress Resistance." Aerospace Medicine 39 (May 1968): 512-18. Kleitman, Nathaniel. "The Sleep Cycle." 60 (May 1960): 677-79.  American' Journal of Nursing  Kornfeld, Donald S. "Psychiatric Complications of Cardiac Surgery." International Psychiatry C l i n i c s 4 (February 1967): 115-31. Kornfeld, Donald S.; Zimberg S.; and Malm J.R. "Psychiatric Complications of Open-Heart Surgery." The New England Journal of Medicine 273 (August 5, 1965): 287-92. Kreuter, Francis Reiter. "What i s Goad Nursing Care?" Nursing Outlook 5 (May 1957): 302-4. Lazarus, H.R., and Hagens, J . H. "Prevention of Psychosis Fallowing Open-Heart Surgery."' American Journal of Psychiatry 124 (March 1968): 1190-95. Long, Barbara. "Sleep." 1969): 1896-99.  American Journal of Nursing 69 (September  Lowry, Fredrick H. "Recent Sleep and Dream Research: C l i n c i a l Implications." Canadian Medical Association Journal 102 (May 1970): 1069-77. Luby, E.D.; Lenzo, Joseph E.; Gottlieb, Jacques S.; Frohman, Charles E.; and G r i s e l l , James L. "Sleep Deprivation: Effects on Behavior, Thinking, Motor Performance and B i o l o g i c a l Energy Transfer Systems." Psychosomatic Medicine 22 (May-June 1960): 182-92.  50 Menaker, Michael. 6B1-B9.  "Biological Clock."  Bioscience 19 (August 1969):  Meyer, Bernard C ; Blacher, Richard S.; and Broun, Fred. "Clinical Study of Psychiatric and Psychological Aspects of M i t r a l Surgery." Psychosomatic Medicine 23 (May-June 1961): 194-218. M i l l s , J . IM. "Human Circadian Rhythms." (January 1966): 129.  Physiological Revieus 46  Nahum, L. H. "Madness i n the Recovery Room From Open-Heart Surgery or They Kept Waking Me Up." Connecticut Medicine 29 (November 1965) : 771-72. Pitorak, Elizabeth. " A l l e v i a t i n g Cardiac Patients' Fear Important Part of Nurse's Role." Hospital Topics 44 (May 1966): 126-27. Pitorak, Elizabeth F. "Open-Ended Care for the Open-Heart Patient." American Journal of Nursing 67 (July 1967): 1452-57. Rae, Nancy Mara. "Caring for Patients Follouing Open-Heart Surgery." American Journal of Nursing 63 (November 1963): 77-82. Sassin, J.F. "Neurological Findings Follouing Short Term Sleep Deprivation." Archives of Neurology 22 (January 1970): 54-56. Walker, Betty. "The Postsurgery Heart Patient: Amount of Uninterrupted Time for Sleep and Rest During the F i r s t , Second, and Third Post-Operative Days i n a Teaching Hospital." Nursing Research 21 (March-April 1972): 164-69. Webb, Welse B., and Agneu, Harmon W. J r . "Variables Associated uith S p l i t Period Regimes." Aerospace Medicine 42 (August 1971): 847-50. Weitzman, E l l i o t D.; Kripke, Daniel F.; Goldmacher, Donald; McGregor, Peter; and Nogeire, Chris. "Acute Reversal of the Sleep-Waking Cycle i n Man." Archives of Neurology 22 (June 1970): 483-89. Williams, R.L.; Agneu, Harman, W. J r . ; and Webb, Wilse B. "Sleep Patterns i n the Young Adult Female; an EEG Study." Electroencepholography and C l i n i c a l Neurophysiology 20 (March 1966) : 264-66. Intensive Care Gives Patients L i t t l e Rest.(Neus) Journal American Medical Association 210 (December 1969): 1682.  51 C. Government Publications U. S. Department of Health, Education and Welfare. Current Research on Sleep and Dreams. Public Health Service Publication Mo. 1389, 1965. D. Unpublished Material E l u e l l , E. L. "Types of Interruptions and Amount of Sleep and Rest Obtained by Six Selected Past-Cardiotomy Patients on the F i r s t Three Postoperative Night." Unpublished Master's thesis, The University of Washington, Seattle, 1969. Garner, Susanna L. "Study of Sleep Deprivation and Nursing A c t i v i t i e s Which Affect Sleep i n Post-Cardiotomy Patients. Unpublished Master's thesis, University of Washington, Seattle, 1969. McFadden, E. H. "A Study of Sleep Deprivation i n Patients Having OpenHeart Surgery." Unpublished Master's thesis, University of Washington, Seattle, 1968.  APPENDIX A CHECKLIST OF INTERRUPTING ACTIVITIES  53  Date:  Postoperative Day: 1  Medication Bed Bath Oral Hygiene Dressing Linen Change Restraints Other Chest Auscult. V i t a l Signs Blood Pressure Temperature I.V. Monitor Lead C.V.P. Hypother.Blanket Turn-Postion Pass. Exercise Ambulation Strip Chest Tube Postural Drainage Cough-Deep Breathe I.P.P.B. IM.T. Tube Care Bag & Suction 02 Therapy Measure Urine Foley Catheter Bedpan-Urinal Fluids Offered Oral Feeding Weight Nurse Comm. c Pt. Pt. I n i t i a t e d Act. Visitors Doctor Housekeeping Laboratory X-Ray Physio. Therapy Environment: Noise Lights Telephone Talking Monitor Alarm  i  2  3  k  5  6  7  a  9  10  11  12  13  lk  15  APPENDIX B CATEGORIES DF TYPES DF ACTIVITIES  55 Categories 1.  of Types of A c t i v i t i e s  IMursing A c t i v i t i e s a)  Comfort medication bed bath o r a l hygiene dressing linen change restraints other  d)  b)  Monitoring chest auscultation v i t a l signs blood pressure temperature I.V. monitor lead C.V.P.  e)  Nutrition and Elimination measure urine foley catheter bedpan - u r i n a l f l u i d s offered o r a l feeding weight  d)  Circulation . hypothermia blanket turn and position passive exercises ambulation  f)  Nurse communicating with patient  2.  Patient I n i t i a t e d A c t i v i t i e s  3.  A c t i v i t i e s of Others personal v i s i t o r s doctors housekeeping s t a f f laboratory s t a f f X-ray physiotherapist  k.  Environment noise lights telephone talking monitor alarm  Respiration s t r i p chest tube postural drainage cough and deep breathe I.P.P.B.  IM.T. tube care bag and suction 0^ therapy  APPENDIX C RANDOM SAMPLE OF TIME FDR OBSERVATION PERIODS  RANDOM SAMPLE OF TIME FOR OBSERVATION PERIODS  Early Postoperative Period 2:00 P.M. - 6:00 A.M.) Mon.  Tues.  2 AM - 6 AM  2 AM - 6 AM 2 PM - 6 PM 10 PM - 2 AM  Sun.  Sat.  Thur.  Fri.  2 PM - 6 PM 6 PM - 10 PM  6 PM - 10 PM 10 PM - 2 AM 10 PM - 2 AM  6 AM - 10 AM 6 PM - 10 PM 10 PM - 2 AM  10 AM - 2 PM 2 PM - 6 PM  10 AM - 2 PM  6 AM - 10 AM 6 PM - 10 PM  10 AM - 2 PM  2 PM - 6 PM 2 PM - 6 PM 6 PM - 10 PM  wed.  Mid Postoperative Period (6:00 A.M. - 2:00 A.M.) 6 PM - 10 PM 10 PM - 2 AM 6 AM - 10 AM Late Postoperative Period (2:00 A.M. - 10:00 P.M.) 6 PM - 10 PM  Total time blacks:  6:00 A.M. - 10:00 A.M. 10:00 A.M. - 2:00 P.M. 2:00 P.M. - 6:00 P.M.  = = =  3 4 5  6:00 P.M. - 10:00 P.M. 10:00 P.M. - 2:00 A.M. 2:00 A.M. - 6:00 A.M.  = = =  7 5 3  10 AM - 2 PM • 2 AM - 6 AM  APPENDIX D TABLES RELATED TD UNINTERRUPTED TIME BLOCKS  TABLE 10 NUMBER AND DURATION OF UNINTERRUPTED TIME BLOCKS IN EACH FOUR-HOUR BLOCK IN THE EARLY POSTOPERATIVE PERIOD Number of Uninterrupted Time Blocks Four-Hour Blocks  5 mins. or less  6-10 mins.  11-20 mins.  Duration 21-30 mins.  mins.  41-50 mins.  31-40  over 50 mins.  2-6 P. M.  32  k  1 .  1  0  0  0  2-6 P.M.  18  5.  1.  1  0  1  0  6-10 P.M.  31  k  2  0  0  0  0  6-10 P.M.  19  4  2  1  0  0  0  10-2 A.M.  27  k  1  1  0  0  0  10-2 A.M.  30  7  1  1  0  0  0  10-2 A.M.  16  .0  0  1  0  1  0  2-6 A.M.  11  2  3  1  1  0  0  2-6 A.M.  29  6  3  0  0  0  0  213  36  lk  7  1  2  0  Total  Ul  TABLE 11 NUMBER AND DURATION OF UNINTERRUPTED TIME BLOCKS IN EACH FOUR-HOUR BLOCK IN THE MID,POSTOPERATIVE PERIOD Number of Uninterrupted Time Blocks  Four-Hour Blocks  Duration 5 mins. or less  6-10 mins.  11-20 mins.  21-30 mins.  31-it0 mins.  41-50 mins.  over 50 mins.  6-10 A.M.  . 21  3  0  0  0  0  0  6-10 A.M.  16  1  5  0  2  0  0  10-2 P.M.  20  7  if  0  0  0  0  10-2 P.M.  11  2  3  0  0  0  0  2-6 P.M.  29  3  0  0  0  0  0  6-10 P.M.  28  1  1  1  0  0  0  6-10P.M.  17  0  1  1  0  0  0  10-2 A.M.  2k  k  if  0  0  0  0  10-2 A.-M.  15  5  3  1  0  0  0  Total  181  26  21  3  2  0  0  cn o  TABLE 12 NUMBER AND DURATION OF UNINTERRUPTED TIME BLOCKS IN EACH FOUR-HOUR BLOCK IN,THE LATE POSTOPERATIVE PERIOD Number of Uninterrupted Time Blacks Four-Hour Blocks  5 mins. or less  6-10 mins.  11-20 mins.  2-6 A.M.  1.5  5  2  6-10 A.M.  21  3  10-2 P.M.  16  2  10-2 P.M.  30  2 -6 P.M.  Duration 21-30 mins.  31-40 mins.  41-50 mins.  2  0  0  0  0  0  0  0  1  0  0  0  0  2  •1  0  0  0  0  25  2  0  0  0  0  0  7  2  2  1  1  0  0  6-10 P.M.  11  4  3  0  0  0  0  6-10 P.M.  25  5  1  0  0  0  0  6-10 P.M.  35  2  0  0  0  0  0  185  27  14  3  1  0  0  2-6 P.M.  Total  over 50 mins.  APPENDIX E TABLES RELATED TD TYPES OF INTERRUPTIONS  63 TABLE 13 NUMBER DF INTERRUPTIONS IN THE TYPES OF ACTIVITY UITHIN THE FOUR-HOUR TIME BLOCKS IN THE EARLY POSTOPERATIVE PERIOD :  Number of Interruptions Types of Activity  Medication Bed Bath Oral Hyg. Dressing Linen Other Chest Ausc, V.S. B. P. Temp. I.V. Monitor C. V.P. Hypo.Blank Turn-Pos. Pass.Ex. Chest Tube Cough D.B. N.T. Tube Bag & Suet. 02 Ther. Meas.Urine Foley Cath. Nur. comm. Pt.Int.Act. Visitors Doctor Lab. X-ray Physio. Environ: Noise Lights Tel. Talking Mon.Alarm Total  Four-Hour Time Blacks 2-6 P.M  2-6 P.M  6-10 P.M.  6-10 P.M.  5 .15 3  2 11 2  ••  1 1 14  3 4 2  ••  4 2  4 7 4  11  B 13  2 6 11 15 1 1  ••  10 1 3  19 1  11  5 17  4 5  •• 8 7  ••  5 1 6 2  ••  1 21 6 3 4 2 4 8  12 3 2 2  ••  10 21 1 1 3 9  ••  4 1 91  4 22  124 152  1 5 1 0.27  10-2 A.M.  10-2 A.M.  3 1 11 2 3 6 5 10  6 2 8 5 5 5  10  11  ••  10-2 A.M. 8  4 6  2 12 2 9 8 5 7  3 4 2. 1 7  7 6 7 3 1 6  17 5 1  8 6 8 1 2 7 8  2-6 2-6 Total A.M. A.M.  4 2  4 1  ••  4 7  3 29  2 0  ••  ••  2 41  11 5  8  1 1  5 22 2 4 10 3  26 3 1 21  42  120  38  •• 1 42 ••  85  98  33 32 6 3 13 52 19 53 36 35 42 8 33  ••  73 1 40 15 19 29 25 7 5 65 126 26 16 5 7 48  109 6 11 •• 115 3 7 2 81 .120  TABLE 14 NUMBER OF INTERRUPTIONS IN THE TYPES OF ACTIVITY UITHIN THE FOUR-HOUR TIME BLOCKS IN THE MID POSTOPERATIVE PERIOD Number of Interruptions  Types of Activity  Four-Hour Time Blocks  Medication Bed Bath Oral Hyg. Dressing Linen Other Chest Ausc. V.S. B. P. Temp. I.V. Monitor C. V.P. Turn.P-as. Pass. Ex Chest Tube Caugh-D.B. 02 Ther. Meas.urine Foley Cath. Fluids Oral feed Nurse comm. Pt.Init.Act Visitors Doctor Housekeep Lab. X-ray Physio. Environ: Noise Lights Tel. Talking Mon.Alarm Total  6-10 A.M.  6-10 A.M.  4 12 2  1 2  . 4 1 3 3 6 4 4 1 2 11 1  1 1 2 3  10-2 P.M.  1 4 4 1  10-2 P.M.  P.Ml  18  3 6 1 15 3 2  •• 4 5 2 4  ••  16  2 2  a 1  3 18 16 4  1 3 2 7  •• •  6 4  1  ••  10  23 ••  8 41  1 2  34 1 2 38 2  |228  2  66  6-10 P.M.  4 13 3  1 14  ••  ••  9 19  5 6 4 5  6 6  •• 13 6 4 5  o  4 20  6-10 P.M.  6 7 18  ••  1 16  10-2| A.M.  8 3 4 4 4 7  1 2 1 3 2 8  ••  18 13 5  2 16 1  ••  1 2  12  4  2 4 2 2  .5 4 17 7 11  10-2 A.M.  5 t m  8  1 18  1 34  23  18  10 1  20 1 3 8  4  4 70  34  ••  11  16  22 5 4 1  21 1  26 1  3 42 2  74  187  191  203  23  ••  24 2 2 13 1 149  •• 9 4  112  110  65 TABLE 15 NUMBER OF INTERRUPTIONS IN THE TYPES OF ACTIVITY UITHIN THE FOUR-HOUR TIME BLOCKS IN THE LATE POSTOPERATIVE PERIOD Number of Interruptions Types of Activity  Medication Bed Bath Oral Hyg. Dressing Linen Other Chest Ausc. V.S. B. P. Temp. I.V. Monitor C. V.P. Turn.Pas. Ambulation Chest Tube Caugh-D.B. 02 Ther. Meas.Urine Bed Pan Fluids Oral Feed Nur.camm. Pt.Int.Act. Visitors Doctor Housekeep' Lab. X-ray Physio. Environ: Noise Lights Tel. Talking Man.Alarm  Four-Hour Time Blocks 2-6 6-10 A.M. A.M.  10-2 P.M.  10-2 P.M.  3 2  3 6 5 2  6 2 4 7 7 2 8  12  6  3 2 3 3  a  4  •• 3 7 7 4 1 6 4 13  5 9 2  •• 4 10  a  5 9 5  •3  > •  1  1 4  3  ••  1 20  35 7 24  1 11  a  37  6 1 23 12 1  ••  a 5 27 7 1 1 1 97  15 1 3 7 3 141  2 10  ••  23 11 ••  1 21 ••  iai  2 2 6 40  •• 6 7 7  a  20  2  6  2 49  la l  2-6 2-6 6-10 P.M. P.M. P.M.  5 3 1 11 13 46 10  3 21 1 4 11 3  16  10  a •• 5 8  a  14  7 5  2 2  ••  6-10 P.M. 1 7  •• 1 13 11 ••  4 2 3 12  •• 1 7  a  ••  4 1  ••  7 22  2 4 14  ••  30 17 1  1 2  21  43  23  9  4  14  ••  •• 1 19 1 211  3 25  4 2  2 1 15 •• 22  6-10 P.M.  156  229  1 26 •• 174  ••  5 19  •• 3 25 2 165  13 14  Total 22 64 5 37 51 91 12 42 48 44 53 1 16 59 17 4 7 39 6 13 6 80 52 233 41 4 4 38 5 177  4 21 2  109 2 14 129 8  179  1533  APPENDIX F NUMBER OF PATIENTS OBSERVED BY SEX ACCORDING TO THE TYPE OF SURGERY  67 TABLE 16 NUMBER DF MALE AND FEMALE PATIENTS •BSERUED ACCORDING TO THE TYPE OF SURGERY Types of Surgery  Number of Patients Male  Female  Aortic l/alv/e Replacement  1  • •  A t r i a l Myoxma  1  • •  • •  3  3  2  • •  2  Single Bypass Graft  k  if  Double Bypass Graft  5  • •  T r i p l e Bypass Graft  1  1  15  12  A t r i a l Septal Defect M i t r a l Valve Replacement Open M i t r a l Commissurotomy  Total  APPENDIX G TABLES RELATED TO INTERRUPTED AND UNINTERRUPTED TIME  69 TABLE 17 NUMBER OF MINUTES OF INTERRUPTED AND UNINTERRUPTED TIME IN EACH FOUR-HOUR BLOCK IN THE EARLY POSTOPERATIVE PERIOD  Four-Hour B l o c k s  Number of M i n u t e s Interrupted Time  Uninterrupted Time  2-6 P.M.  103  137  2-6 P.M.  78  162  6-10 P.M.  131  109  6-10 P.M.  108  132  10-2 A.M.  110  130  10-2 A.M.  93  147  10-2 A.M.  142  98  2-6 A.M.  63  177  2-6 A.M.  87  153  1,120  1,040  Total  70  TABLE 18 NUMBER DF MINUTES DF INTERRUPTED AND UNINTERRUPTED TIME IN EACH FOUR-HOUR BLOCK IN THE MID POSTOPERATIVE PERIOD Number of Minutes Four-Hour B l o c k s  Interrupted Time  Uninterrupted Time  6-10 A . M .  193  47  6-10 A . M .  54  186  10-2 P.M.  67  173  10-2 P.M.  153  87  2-6 P.M.  163  77  6-10 P . M .  128  112  6-10 P.M.  172  68  10-2 A . M .  94  146  10-2 A . M .  87  153  Total  1,320  840  71 TABLE 19 NUMBER OF MINUTES DF INTERRUPTED AND UNINTERRUPTED TIME IN EACH FDUR-BLDCK IN THE LATE POSTOPERATIVE PERIOD Number of Minutes Four-Hour Blacks  2-6 A.M.  Interrupted Time  Uninterrupted Time  72  168  6-10 A.M.  119  121  10-2 P.M.  176  64  10-2 P.M.  158  82  2-6 P.M.  183  57  2-6 P.M.  120  12D  6-10 P.M.  145  95  6-1-0 P.M.  141  99  6-10 P.M.  153  87  1,533  627  Total  

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